All right. Thanks for having me. It's hard to follow, Chris, so bear with me. I get to talk about the most important letter, sorry, Chris, the letter F, the family engagement and involvement piece. Mobility is good and all, but I think for the family piece kind of wins. So I think thanks for the nice introduction, Julie, I'm not going to talk more about that. I do have some disclosures, but hopefully none of this is relevant to this talk. And so we're going to talk about family engagement, which is an important piece and it's very personal because I'll talk about my own personal journey through this in the last few years, how things have changed since we last met in person. We're talking about family centered care, look at some basic principles of guidelines, look at the 2017 guidelines, and then look at pre-pandemic and then post-pandemic, what's changed, what's evolved in this space briefly. And look at some successful strategies moving forward. So we kind of knew this pre-pandemic, right? We knew we had some issues. How many of you love healthcare from a family perspective? No. No, it's just kind of a thumbs down in the ICU experience if you're part of a family, right? We struggled with this for decades. We knew patients were isolated from their families. We had lots of studies to show that. We knew that communication issues were ubiquitous in the ICU. And there were a lot of barriers to ICU visitation. I know many of you in the audience have had, you know, family visitation that was liberal, but for a lot of us who are older and grayer, we remember times where we were kicked out of the ICUs when we visited families routinely. There were certain hours you had to go and it was really challenging. We learned about caregiver suffering early in the last couple of decades. This sort of had increased in prevalence and knowledge base. And then we also knew that patient safety and experience matters with now healthcare systems, organizations looking at patient experience in a transparent manner as much as possible. And that's becoming important. So in that space, family-centered care kind of emerged as an important approach towards healthcare that's respectful to and responsive to individuals' families' needs and values. We had a plenary session this morning about diversity, equity, inclusion by our keynote speaker. This is core to DEI work, right? So I have a leadership role in DEI work. So seeing people where they are, their values and everything, this is core to that element. And so what else is involved in that? Aspects of collaboration, respect and dignity, decision making, information sharing. All of this is part of being truly patient and family engaged. And the SCCM has helped in this process. But people like Dr. Judy Davidson, who's, I think, giving a special session tomorrow about some of these issues, in 2017, led an effort about the family-centered guidelines. And they advocated for a few things. Flexible and open presence. The option for families to participate in team rounds. That may not be for everybody. It may be intimidating for them. But the option to do that. Even being present during codes. Now, we just happened to witness, for those of you who watched that incredible scene in the Bengals-Bills game a couple weeks ago, you saw the impact of the people who watched that code happen in real life and how that affected, you know, incredible athletes broke down in front of us on national TV. And you can see what that looks like. We were advocating for that a while ago. But we still today don't do that in a lot of our ICUs. But their team advocated for this a while ago. And so they also looked at sort of all kinds of data. They assembled some of the data about some of the education programs, the peer-to-peer in the neonatal ICUs, talked about educational leaflets, and realized people do this differently. Some people do ICU diaries. Some people look at validated decision support tools. But really what came across is a better way to communicate. And this team shows and advocated for what's called a value mnemonic. That they want patients and families to be considered, in order to sort of approach them in a great way, you've got to think about them in terms of like look at the V for value their comments, A, acknowledge the family's emotions, L, listen, U, understand the patient as a person, and E, elicit family questions. And my wife tells me this works really well for teenagers as well. So I've adopted this to my home life. And it works out incredibly well. It's been much more successful. And then the communication, how do you do the communication? So over the course of my life, I've been fortunate to have a lot of mentors who teach me about family-based communication. And oftentimes, you still end up not knowing how to move forward, right? We have family conferences. We have structured communication approaches. We have family members of dying patients. Sometimes they don't have a real way to sort of bereave. And so we talked about having a real way to grieve, having things like bereavement brochures or resources for them. And then the other ultimate piece is that ICU clinicians should receive communication training. Now, having gone through med school, residency, fellowship, and then training afterwards, you're like, really? Communication training? After all those years of education? And I'm surprised at how little many of us get trained, including myself, about how to communicate effectively, genuinely, with empathy. And I think that's something that we'll hopefully revisit in the future, in a future talk. The idea of consultations, having palliative care consultations, almost to the point where I think some places now have gone almost too far, where the palliative care team assumes all communication. And we can talk about that forever. But ethics consultations, psychologist interventions potentially being available, social worker participation in family conferences, we can understand some of the social elements and coordination and needs. Family navigators. So the other turban I wear is in the lung cancer space. In the lung cancer space, we have tons of navigators, navigators that help coordinate visits, help coordinate testing, diagnostics, procedural results, all those things. In the ICU, how many of you have navigators? But wouldn't that be kind of cool, right, to have someone to help us understand logistics? Where's the family right now? How are they doing mentally, emotionally, and even physically? Where are they geographically? Spiritual support, all those aspects are being thought about, about how to approach this with more sophistication and ideally more impact. The group also advocated for operational environmental issues, things like protocols to adjust sedation. We heard a lot about that earlier on. But nurses be involved in goals of care. How many have gone to a family care discussion, but without the nurse, only to come back there's a discordant view of where the patient's at and what values the patient, family, and the team has. Hospital policies for family-centered care, noise reduction, environmental hygiene, this is all important and part of the guidelines, and even family sleep made it to the guidelines at some point. So they also established some goals, and I think the most important one is the first is establish a trusting relationship, but also provide emotional support, helping families understand the diagnosis, treatment options, and such. And then allowing patients to be seen as a person, creating conditions for careful deliberation about difficult decisions, quiet rooms, sort of ways to sort of minimize disruption. And all this was thought about pre-pandemic. Oh, sorry, I need to go backwards. And so in this space, when I teach my residents or trainees or others, we think about different mechanisms of how to get to good patient family engagement, family-centered rounds, daily updates, portals, interdisciplinary family meeting, and they're all different. And they all work differently for different people. I don't think any of us really understand which one works better for each individual family. And some of them just have some pros and some cons. Not everyone's perfect. Family-centered rounds, it's great when the family's present, when they want to be involved and they have good questions and they know how to sort of work that group. But it can also be awkward for some. It can be inefficient for some teams. Daily updates, when you call them every day, well, sometimes I forget, you know, and it can be an awkward conversation depending on how it's done. Other times it can be great. Patient portals, how many of you have family members with patient portals that have no idea how to navigate? Well, we went through that. That was horrible, right? How do you navigate patient portals? They're not easy. They're not made to be intuitive all the time. And then the interdisciplinary family meetings, they're oftentimes are a traditional mechanism, but they can be hard to coordinate logistically. And that was pre-pandemic. I did also like this sort of thing of some authors out there had advocated for trying to put a cadence or a rhythm to the family interactions. Start out kind of giving them information, move towards a more systematic interaction, and then as the disease progresses or the complexities increase, things happen, kind of become more structured on a regular cadence. I tried to roll this out to our teams. I just didn't get any traction. But I'm still going to want to revisit that. Other teams looked at things like ICU diaries. They looked at sort of the empathy training based on some neurosciences. Even before the pandemic, we were talking about burnout, wellness, resilience in this space, as well as issues of self-awareness, institutional awareness, as well as a larger movement called the compassionate care movement, which I'm part of. And how many of you had COVID lavender in your teams? Or how many of you have Schwartz rounds? As I get older, those are the best rounds that I really enjoy, to be honest with you. I mean, I like important database information, but I find that oftentimes those shared spaces, those safe spaces, those brave spaces, as some people call them, are oftentimes very helpful. Julie and the team also led things like the liberation minimum data set. You know, the idea is can we measure some of these basic things that families need? So we started collecting some of this data in our ICUs and other ICUs around the country and started thinking about, you know, what things are important, what are must-haves, what are nice-to-haves in most ICUs to be good at patient and family engagement. And I'm not going to go through these. These are all sort of publicly available. And then the pandemic hit, right? And the earth just stopped, right? We made all this momentum, all this energy towards patient-family engagement, and then all of a sudden, as you kind of heard earlier and many of you experienced, right, me, I already had, I had to wear a papper every day to work. I had to manage patients and families, talking to them virtually. People couldn't hear me, couldn't see me, and then they couldn't really understand what I was saying all the time at work. It became a very difficult time for a lot of us. And in that journey, I learned a lot about this space that I had been speaking about before the pandemic, but I got to see it from a different lens through those last several years, especially that first year or so. And a lot of us were trying to figure out, you know, should we allow families back? And I think a lot of us said, yes, we should allow families back at the bedside, but, you know, hopefully safety. And there's a bunch of reasons why we should let them back, and a lot of us debated this for some time. I like this sort of really long, I apologize for the font in this room. I didn't realize we were in this big room. I thought it would be a small little room that we'd be speaking in. But we talked about sort of the different reasons to do that. I think the reasons are listed here, but the idea of psychological distress for the families was way up there. I mean, it's really hard. How many of you had family members, you know, have COVID? Well, I went through that with my parents in the ICUs with COVID. I didn't know what's going on. Nobody would talk to me. I couldn't get them to, anyone to communicate with me effectively. That was very distressful. Then we also had basically family members and, sorry, the physical and symptoms, the family actually couldn't really help a whole lot with these things. And then we also ourselves had psychological symptoms. The PTSD, the psychological grief of the pandemic, the lockdown, the effects it had on the entire family were just immense. And then the issues go on and on. The impact was enormous. And I think for all of us, it was just extraordinarily hard. I think many of us are still unpacking all that went through. I know many people have moved on. Some have had a hard time because of how hard it was. And so I'll just sort of say that for a lot of us, we really want to get family members back in the ICUs. And I know it was hard. And as we come through, I know pockets of our country are having surges again, and we have to revisit these policies again, but it's adding a whole lot. I do want to touch on a couple of points, which I would think none of us were prepared for. One was we talked about the importance of trust and trusting relationship, but the infodemic, the information aspects of how we had to manage what was scientifically felt to be valid or recommended versus what the patients and families felt. We struggled with that piece quite a bit. We didn't really have a formula or data to understand how to manage TikTok information and YouTube information versus scientific literature. We wrestled with that so much. And so a lot of that became something else, another skill set we had to learn to sort of go through. And that was tough. The unkindness that occurred in that space, violence, aggression towards healthcare workers, I mean, those are things that, honestly, as much as we've had some challenges, I don't remember to that degree having to manage some of that stuff, and some of that is still present today, as you all know. So we're starting to think through some of those aspects, and how can we manage those a little bit better? And so the authors of this article actually thought of some strategies, for example, is, you know, if we have time constraints, we can't update families, can we think about navigators, whether that be a separate person or actually just someone on the team can help manage some of that. Miscommunication. I've sometimes called the wrong person virtually or hit the wrong iPad button or somebody else answers the phone. How do we manage information issues in the virtual world? We started thinking about other ways to communicate and thinking about newer technologies. Now that we've understood virtual technologies better, can we really understand that and make it easier to plug and play these things? And I think there's a way. The aspects of confidentiality and stuff like that we're still wrestling with. But the idea of additional access, and I think now that cell phones and technology and the public is aware of virtual technologies more than ever, I think we're hopeful that we can actually leverage some of the virtual technology to help patients and families engage better in the future. I like this study a lot from this published this last year, earlier this year, and also was on SCCM podcast on the website. The idea, this author actually went ahead and gave surrogates of nondecisional critically ill adults who had a high risk of mortality basically, and basically did summaries of the patient's illness daily for the family. And the investigator did the summary, not the primary clinicians. Pretty exhausting on his part, but it was interesting to me that in two weeks the anxiety, depression, acute stress scores from the family, from the surrogates actually improved intervention. I just think about that quite a bit because I wish someone had done that for me when my father was sick in the ICU, or my mother was sick in the ICU, or my friends. For those who don't know, India got decimated during the pandemic, and I'm at daytime wearing a papper, working in the ICU, at nighttime managing WhatsApp and ventilator waveforms at night. So I'm up all night thinking about these things, and no one's really telling me what's really happening. It's extraordinarily stressful. And so the family engagement, just as we finish up, basically is something that we're still learning. Promising solutions like new virtual tools, new options, but no single recipe for success. I would say there's an urgency now, as I think the overall sort of climate in the country has changed where patients and families want to trust their healthcare workers, and I think we should allow that to happen, but we have to prepare for that and do it. To do that, you have to have some sense of urgency, and I would say make it personal. And think about new ways of thinking of this. Think of a continuous journey. There's a lot of creativity out there, and the SCCM has a great number of talent, a lot of talent out there that wants to start thinking about ways how to approach patients and families differently, knowing what we know now. Measure. The minimum data set's great. Maybe it's outdated. Maybe we have to think about different ways of thinking about this space. And then I would say share your stories. Tomorrow morning, we get the treat of, in the plenary session, to hear two fantastic stories tellers of our lifetime, Drs. Glock and Flockin. Who's going to go to that session? I mean, even no matter what you think about social media, the way they tell stories is just so impactful. And so I encourage you all to tell your stories and start thinking about what are other ways to impact so that we can have the resources and the bandwidth and the methodologies to really drive home patient family-based care. Thank you very much. I'm Jaspal Singh, and if you have any questions, I'll be up here for a little while.

family engagement

healthcare

ICU

communication

COVID-19 pandemic